Patients Follow 3 Different Rate-of-Recovery Patterns After Anterior Cruciate Ligament Reconstruction Based on International Knee Documentation Committee Score.

PURPOSE: To determine whether subgroups of patients exist based on the rate-of-recovery pattern of International Knee Documentation Committee (IKDC) scores after anterior cruciate ligament reconstruction (ACLR) and to determine clinical predictors for these subgroups. METHODS: Patients who underwent primary or revision ACLR at a single institution from January 2014 to January 2019 were identified. Latent class growth analyses and growth mixture models (GMMs) with 1 to 6 classes were used to identify subgroups of patients based on functional rate-of-recovery patterns by use of preoperative, 1-year postoperative, and 2-year postoperative IKDC scores. RESULTS: A total of 245 patients who underwent ACLR were included in the analysis. A 3-class GMM was chosen as the final model after 6 different models were run. Class 1, showing improvement from preoperatively to 1-year follow-up, with sustained improvement from 1 to 2 years postoperatively, constituted 77.1% of the study population (n = 189), whereas class 2, showing functional improvement between 1- and 2-year follow-up, was the smallest class, constituting 10.2% of the study population (n = 25), and class 3, showing slight improvement at 1-year follow-up, with a subsequent decline in IKDC scores between 1- and 2-year follow-up, constituted 12.7% of the study population (n = 31). Revision surgery (P = .005), a psychiatric history (P = .025), preoperative chronic knee pain (P = .024), and a subsequent knee injury within the follow-up period (P = .011) were the predictors of class 2 and class 3 rate-of-recovery patterns. Patient demographic characteristics, graft type, and concomitant ligament, meniscus, or cartilage injury at the time of surgery were not associated with the different recovery patterns described in this study. CONCLUSIONS: Patients may follow different rate-of-recovery patterns after ACLR. By use of the GMMs, 3 different rate-of-recovery patterns based on IKDC scores were identified. Although most patients follow a more ideal rate-of-recovery pattern, fewer patients may follow less favorable patterns. Revision surgery, a history of psychiatric illness, preoperative chronic knee pain, and a subsequent knee injury within the follow-up period were predictive of less favorable rate-of-recovery patterns. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Establishing Clinically Significant Outcomes After Anterior Cruciate Ligament Reconstruction in Pediatric Patients.

PURPOSE: The purpose of this study was to establish clinically significant outcome values for the minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) after anterior cruciate ligament reconstruction (ACLR) in the pediatric and adolescent populations and to assess factors that were associated with achieving these outcomes. METHODS: Patients between the age of 10 to 21 who underwent ACLR between 2016 and 2018 were identified and patient-reported outcomes (PROs) were collected preoperatively and postoperatively. Intraoperative variables collected included graft choice, graft size (diameter), graft fixation method, and concomitant procedures. PROs collected for analysis were the International Knee Documentation Committee Score (IKDC) and Knee Injury and Osteoarthritis Outcome Score (KOOS). MCID and PASS were calculated using receiver operating characteristic with area under the curve analyses for delta (ie, baseline-to-postoperative change) and absolute postoperative PRO scores, respectively. RESULTS: A total of 59 patients were included in the analysis. Of the entire study population, 53 (89.8%) reported satisfaction with their surgical outcome. The established MCID threshold values based on the study population were 33.3 for IKDC, 28.6 for (KOOS) Symptoms, 19.4 for Pain, 2.9 for activities of daily living (ADL), 45.0 for Sport, and 25.0 for Quality of Life (QoL). Postoperative scores greater than the following values corresponded to the PASS: 80.5 for IKDC, 75.0 (KOOS) Symptoms, 88.9 for Pain, 98.5 for ADL, 75.0 for Sport, and 68.8 for QoL. CONCLUSION: Clinically meaningful outcomes including MCID and PASS were established for pediatric ACLR surgery using selected PRO measures, IKDC, and KOOS. Patient age, sex, graft type, and graft size were not associated with greater achievement of these outcomes. In contrast, collision sports, fixed-object high-impact rotational landing sports, and concomitant meniscectomy surgery were associated with a decreased likelihood of achieving clinically significant improvement. However, findings must be interpreted with caution due to limitations in follow-up and sample size. LEVEL OF EVIDENCE: Level IV: case series.

Establishing the Minimal Clinically Important Difference and Patient-Acceptable Symptomatic State After Arthroscopic Meniscal Repair and Associated Variables for Achievement.

PURPOSE: To establish the minimal clinically important difference (MCID) and patient-acceptable symptomatic state (PASS) after arthroscopic meniscal repair and identify the factors associated with achieving these outcomes. METHODS: This is a retrospective study with prospectively collected data. Patient-reported outcome measures (PROMs) were collected from April 2017 to March 2020. All patients who underwent arthroscopic meniscal repair and completed both preoperative and postoperative PROMs were included in the analysis. MCID and PASS were calculated via half the standard deviation of the delta PRO change from baseline (for International Knee Documentation Committee Score [IKDC]) and via anchor-based methodology (Knee Injury and Osteoarthritis Outcome Score [KOOS] subscales). RESULTS: Sixty patients were included in the final analysis. The established MCID threshold values were 10.9 for IKDC, 12.3 for KOOS Symptoms, 11.8 for KOOS Pain, 11.4 for KOOS Activities of Daily Living (ADL), 16.7 for KOOS Sport, and 16.9 for KOOS Quality of Life (QoL). Postoperative scores greater than the following values corresponded to the PASS: 69.0 for IKDC, 75.0 for KOOS Symptoms, 80.6 for KOOS Pain, 92.7 for KOOS ADL, 80.0 for KOOS Sport, and 56.3 for KOOS QoL. Higher preoperative PRO scores were associated with lower likelihood of achieving MCID. Concomitant ligament procedures were associated with a higher likelihood of achieving PASS. Tears to both menisci were associated with decreased likelihood of achieving MCID and PASS for IKDC. Horizontal tears were associated with decreased likelihood of achieving PASS for IKDC and KOOS. Complex tears were associated with decreased likelihood of achieving MCID for KOOS. CONCLUSION: Clinically meaningful outcomes such as MCID and PASS were established for meniscal repair surgery using selected PROMs for IKDC and KOOS subscales. Variables more likely to be associated with achieving these outcomes include lower preoperative PRO score and concomitant ligament procedure, whereas higher preoperative PRO score, tearing of both medial and lateral menisci, and horizontal and complex tear classifications were associated with decreased likelihood of achieving these outcomes. LEVEL OF EVIDENCE: IV, retrospective case series.

Hip Arthroscopy for Femoroacetabular Impingement Improves Sleep Quality Postoperatively.

PURPOSE: To describe the prevalence of abnormal sleep quality in patients with femoroacetabular impingement syndrome and to determine whether arthroscopic hip preservation surgery with cam/pincer correction, labral preservation, and capsular plication can improve sleep quality postoperatively. METHODS: All patients undergoing primary hip arthroscopy for cam/pincer correction who failed nonoperative management between March 1, 2017, and July 1, 2017, were administered a validated sleep quality questionnaire-the Pittsburgh Sleep Quality Index (PSQI)-preoperatively and at 3, 6, 12, and 24 weeks postoperatively. Exclusion criteria included patients undergoing revision arthroscopy, gluteus medius repair, or a contralateral procedure during the follow-up period and those with known sleep disorders. A global (total) PSQI score >5 indicates poor sleep quality. The Hip Outcome Score-Activities of Daily Living, Hip Outcome Score-Sports Specific Subscale, modified Harris Hip Score, and International Hip Outcome Tool-12 were used to assess functional outcomes. A repeated measures analysis of variance with post hoc Greenhouse-Geisser and Bonferroni corrections was conducted to determine statistically significant changes in sleep patterns. RESULTS: A total of 52 patients (94.6%) were included in the final analysis. The mean (± standard error) patient age was 37.8 ± 1.9 years, and body mass index was 27.6 ± 0.7. Preoperatively, 49 (94.2%) of patients experienced poor sleep quality, defined as a global PSQI score >5, with a mean PSQI score of 9.8 ± 0.6. At 24 weeks postoperatively, 10 (21.7%) of patients experienced poor sleep quality with a mean PSQI score of 2.2 ± 0.2. All patients had significant improvements in all hip outcome instruments at 24 weeks postoperatively (P < .001). CONCLUSIONS: Preoperatively, patients with femoroacetabular impingement syndrome have a high prevalence of sleep disturbance. These patients experience subsequent improvement in sleep disturbance after arthroscopic hip surgery early in the postoperative period. LEVEL OF EVIDENCE: Level IV, case series.

The Influence of Pain in Other Major Joints and the Spine on 2-Year Outcomes After Hip Arthroscopy.

PURPOSE: To determine whether patients who have pain in other major joints or the spine have poorer postsurgical outcomes than patients without comorbid orthopaedic pain. METHODS: We performed a review of a prospectively maintained institutional surgical registry of patients who underwent hip arthroscopy between January 1, 2012, and July 16, 2015, by a single surgeon, with a minimum of 2 years of postoperative follow-up. A musculoskeletal morbidity (MSM) score was assigned to each patient preoperatively based on the presence of pain in other joints and the spine (grade 1, hip only; grade 2, hip and other major joints without spine; grade 3, hip with spine; and grade 4, hip and other major joints with spine). Preoperatively and at 2 years postoperatively, functional outcomes were measured using the Hip Outcome Score-Activities of Daily Living (HOS-ADL), and the percentages of patients achieving a minimal clinically important difference (MCID) and patient-acceptable symptom state (PASS) were calculated. RESULTS: In total, 821 patients were identified, of whom 700 (85.3%) completed 2-year follow-up. Preoperatively, MSM grade 1 patients had a higher HOS-ADL than grade 2 patients (P = .02), but there was no difference between grade 1 and grade 3 patients (P = .63) or between grade 1 and grade 4 patients (P = .14). Likewise, there was no difference in the preoperative HOS-ADL among grades 2, 3, and 4. Patients with MSM grades 1 and 2 were younger than those with grades 3 and 4. At 2 years postoperatively, MSM grade 1 patients had higher HOS-ADL values than grade 3 (P = .01) and grade 4 (P = .02) but not grade 2 (P = .07) patients. Overall, 84% of patients showed an MCID and 72% of patients achieved a PASS with regard to the HOS-ADL. There were no statistically significant differences among MSM grades in terms of the MCID or PASS. CONCLUSIONS: Overall, 84% of patients improved with hip arthroscopy by MCID criteria for the HOS-ADL. Patients with no pain in other joints (MSM grade 1) had better 2-year postoperative HOS-ADL values after hip arthroscopy than patients with spine pain (grades 3 and 4). However, there were no significant differences in the MCID or PASS among patients with regard to MSM grade. A total of 40.5% of patients who underwent hip arthroscopy had pain in another joint. A limitation, however, is that there is potential for a type II error, in that there may not have been a sufficient number of patients studied to detect a significant difference in outcome among patients with different grades of musculoskeletal comorbidity. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

High Rate of Return to Swimming After Hip Arthroscopy for Femoroacetabular Impingement.

PURPOSE: To evaluate patients' ability to return to swimming after hip arthroscopy for femoroacetabular impingement syndrome (FAIS) with capsular closure. METHODS: Consecutive FAIS patients who had undergone hip arthroscopy for the treatment of FAIS by a single fellowship-trained surgeon were reviewed. The inclusion criteria included patients with a diagnosis of FAIS who self-reported being swimming athletes with a minimum clinical follow-up duration of 2 years. For all patients, we assessed demographic data; preoperative physical examination findings, imaging findings, and patient-reported outcome (PRO) scores including the modified Harris Hip Score, Hip Outcome Score-Activities of Daily Living subscale, Hip Outcome Score-Sports-Specific subscale, and visual analog scale for pain; and postoperative examination findings and PROs at a minimum of 2 years after surgery, including a swimming-specific questionnaire. RESULTS: The study included 26 patients (62% female patients; average age, 31.3 ± 7.2 years; average body mass index, 24.2 ± 2.7 kg/m2). Preoperatively, 24 patients (92%) were unable to swim at their preinjury level, and swimming was either decreased or discontinued entirely at an average of 6.0 ± 4.0 months before surgery. All 26 patients (100%) returned to swimming at an average of 3.4 ± 1.7 months after surgery, including 14 (54%) who returned at a higher level of performance than their preoperative state, 10 (38%) who returned to the same level, and 2 (7%) who returned at a lower level. The ability to return at a higher level of performance was not associated with age (P = .81), sex (P = .62), or body mass index (P = .16). At an average of 31.2 ± 4.95 months' follow-up, postoperative PRO scores improved significantly from preoperative values (Hip Outcome Score-Activities of Daily Living subscale from 68.5 ± 19.9 to 93.9 ± 5.7, P < .0001; Hip Outcome Score-Sports-Specific subscale from 44.0 ± 21.0 to 85.2 ± 16, P < .0001; and modified Harris Hip Score from 59.5 ± 12.1 to 94 ± 8.6, P < .0001). The average patient satisfaction level was 93% ± 9%. CONCLUSIONS: Recreational and amateur swimmers return to swimming 100% of the time after hip arthroscopy for FAIS, with just over half returning at a higher level, and most of these patients return within 4 months after surgery. This information is critical in counseling patients on their expectations with respect to returning to swimming after hip arthroscopy for FAIS. LEVEL OF EVIDENCE: Level IV, case series.

Utility of Modern Arthroscopic Simulator Training Models: A Meta-analysis and Updated Systematic Review.

PURPOSE: To determine the utility of modern arthroscopic simulators in transferring skills learned on the model to the operating room. METHODS: A meta-analysis and systematic review of all English-language studies relevant to validated arthroscopic simulation models using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines from 1999 to 2016 was performed. Data collected included the specific simulator model, the joint used, participant demographic characteristics, participant level of training, training session information, type and number of tasks, pre- and post-training assessments, and overall outcomes of simulator performance. Three independent reviewers analyzed all studies. RESULTS: Fifty-seven studies with 1,698 participants met the study criteria and were included. Of the studies, 25 (44%) incorporated an arthroscopic training program into the study methods whereas 32 (56%) did not. In 46 studies (81%), the studies' respective simulator models were used to assess arthroscopic performance, whereas 9 studies (16%) used Sawbones models, 8 (14%) used cadaveric models, and 4 (7%) evaluated subject performance on a live patient in the operating room. In 21 studies (37%), simulator performance was compared with experience level, with 20 of these (95%) showing that clinical experience correlated with simulator performance. In 25 studies (44%), task performance was evaluated before and after simulator training, with 24 of these (96%) showing improvement after training. All 4 studies that included live-patient arthroscopy reported improved operating room performance after simulator training compared with the performance of subjects not participating in a training program. CONCLUSIONS: This review suggests that (1) training on arthroscopic simulators improves performance on arthroscopic simulators and (2) performance on simulators for basic diagnostic arthroscopy correlates with experience level. Limited data suggest that simulator training can improve basic diagnostic arthroscopy skills in vivo. LEVEL OF EVIDENCE: Level IV, systematic review of Level I through IV studies.

Anatomy of the Pudendal Nerve and Other Neural Structures Around the Proximal Hamstring Origin in Males.

PURPOSE: To define the anatomy of the pudendal nerve in relationship to the proximal hamstring and other nearby neurological structures during proximal hamstring repair. METHODS: Six fresh-frozen human cadaveric hemi-pelvises from male patients ages 64.0 ± 4.1 years were dissected in prone position with hips in 10° flexion to identify the relationship of proximal hamstring origin to surrounding neurologic structures including the pudendal nerve, sciatic nerve, and posterior femoral cutaneous nerve. Two independent observers used digital calipers to measure distances. RESULTS: The pudendal nerve emerged at the inferior border of the piriformis muscle 6.3 ± 1.4 cm from the superior aspect of the proximal hamstring origin. It passed the superior border of the sacrotuberous ligament 3.0 ± 0.6 cm from the superior aspect and 3.9 ± 0.7 cm from the medial aspect of the hamstring origin. It crossed the inferior border of the sacrotuberous ligament 3.0 ± 0.4 cm from the superior aspect and 2.7 ± 0.7 cm from the medial aspect of the proximal hamstring origin. The shortest distance from the hamstring origin to the pudendal nerve was 2.6 ± 0.5 cm from the superior aspect and 2.3 ± 0.8 cm from the medial aspect. The shortest distance from the hamstring origin to the pudendal nerve was located deep to the sacrotuberous ligament in all cadavers. The sciatic nerve was an average of 1.1 ± 0.1 cm lateral to the lateral aspect of the proximal hamstring origin. The posterior femoral cutaneous nerve was located between the hamstring origin and the sciatic nerve, 0.7 ± 0.2 cm lateral to the lateral aspect of the proximal hamstring origin. CONCLUSIONS: The proximal hamstring origin lies in close proximity to surrounding nerves, including the pudendal, sciatic, and posterior femoral cutaneous nerves. CLINICAL RELEVANCE: Knowledge that the pudendal nerve lies 2 to 3 cm superior and medial to the proximal hamstring origin may help to prevent iatrogenic damage during surgical dissection and retraction when performing proximal hamstring repair or deep gluteal space endoscopy.

How many innings can we throw: does workload influence injury risk in Major League Baseball? An analysis of professional starting pitchers between 2010 and 2015.

BACKGROUND: There has been increasing interest regarding the association between pitch counts, as well as total workload per season, and the risk of injury among Major League Baseball (MLB) starting pitchers. METHODS: We used publicly available databases to identify all MLB starting pitchers eligible for play who made at least 5 starts in seasons between 2010 and 2015. For all included pitchers, annual pitching statistics (number of starts, total season pitch counts, total season inning counts, and average pitch count per game started) and annual disabled list (DL) information (time on DL for any reason and time on DL related to upper extremity, lower extremity, or axial body injury) were collected. A multiple logistic regression analyzed games started, pitch counts, innings pitched, and pitches per start during all previous seasons as a risk factor for injury in the current season, controlling for previous injury. RESULTS: A total of 161 starting MLB pitchers met the inclusion criteria. With the exception of total innings pitched from 2010-2011 being significantly associated with DL placement in 2012 (no DL, 310.5 ± 97.5 innings; DL, 344.7 ± 85.9 innings; P = .040), no other finding for starts, pitch counts, innings, or pitches per start in the cumulative years from 2010-2014 had a significant association with pitcher placement on the DL for any musculoskeletal reason or for an upper extremity reason between 2011 and 2015. CONCLUSIONS: In this study, we demonstrate that there is no association between preceding years of cumulative pitches, starts, innings pitched, or average pitches per start and being placed on the DL for any musculoskeletal reason.

Length of time between surgery and return to sport after ulnar collateral ligament reconstruction in Major League Baseball pitchers does not predict need for revision surgery.

HYPOTHESIS: Pitchers who return to sport (RTS) sooner will have a higher risk of revision ulnar collateral ligament reconstruction (UCLR) than those who return later. METHODS: All professional (major and minor league) baseball pitchers who underwent UCLR between 1974 and 2016 were identified. Date of the index UCLR was recorded. The date of the first game back at any professional level after surgery and the date the pitcher returned to the same level of play (if applicable) were recorded. Length of time between these dates was compared for pitchers who required a revision UCLR and those who did not. RESULTS: Overall, 569 pitchers (average age, 24.8 ± 4.1 years) underwent UCLR and had reliable game logs after surgery. No statistically significant difference existed in the length of time to RTS at any professional level or at the same professional level between those pitchers who did not require a revision UCLR and those who did (P = .442, P = .238). Pitchers who required revision UCLR returned to any level of play almost 2 months earlier (14.7 vs. 16.5 months) and returned to the same level of play >2 months earlier (15.2 vs. 17.7 months) than matched controls who did not require revision UCLR, although this was not statistically significant (P = .179, P = .204). CONCLUSION: No statistically significant difference existed in the length of time to RTS after UCLR in professional baseball players who required a revision UCLR and those who did not.

The Impact of Fatigue on Baseball Pitching Mechanics in Adolescent Male Pitchers.

PURPOSE: To determine if shoulder and elbow kinematics, pitching velocity and accuracy, and pain change during a simulated baseball game in adolescent pitchers. METHODS: Adolescent male pitchers aged 13 to 16 years were included. Pitchers were excluded if they had undergone previous shoulder or elbow surgery, currently had a known shoulder or elbow injury, or were unable to complete the simulated game for any reason. Shoulder range of motion was assessed before and after the game. Velocity and accuracy were measured for every pitch, and every 15th pitch was videotaped from 2 orthogonal views in high definition at 240 Hz. Quantitative and qualitative mechanics were measured from these videos. Perceived fatigue and pain were assessed after each inning using a visual analog scale. Data were statistically analyzed using a repeated-measures analysis of variance. RESULTS: Twenty-eight elite adolescent pitchers were included. These pitchers, on average, were aged 14.6 ± 0.9 years (mean ± standard deviation), had been pitching for 6.3 ± 1.7 years, and threw 94 ± 58 pitches per week. Our experimental model functioned as expected in that pitchers became progressively more fatigued (0.3 ± 0.6 to 3.5 ± 2.1), had more pain (0.1 ± 0.4 to 1.6 ± 2.2), and pitched with a lower velocity (73 ± 5 mph to 71 ± 6 mph) as pitch number increased (P < .001, P = .001, and P < .001, respectively). Knee flexion at ball release progressively increased (49° ± 15° to 53° ± 15°) with pitch number (P = .008). Hip-to-shoulder separation significantly decreased as pitch number increased, from 90% ± 40% at pitch 15 to 40% ± 50% at pitch 90 (P < .001). Upper extremity kinematics remained unchanged (P > .271 in all cases, 91% power for elbow flexion at ball release). External rotation and total range of motion in the pitching shoulder significantly increased after pitching (P = .007 and P = .047, respectively). CONCLUSIONS: As pitchers progress through a simulated game, they throw lower-velocity pitches, become fatigued, and have more pain. Core and leg musculature becomes fatigued before upper extremity kinematics changes. CLINICAL RELEVANCE: On the basis of these results, there is the potential that core strengthening and leg strengthening may be valuable adjuncts to prevent upper extremity injury. Further studies specifically looking at this must be conducted.

Hip Arthroscopy Surgical Volume Trends and 30-Day Postoperative Complications.

PURPOSE: To determine hip arthroscopy surgical volume trends from 2006 to 2013 using the National Surgical Quality Improvement Program (NSQIP) database, the incidence of 30-day complications of hip arthroscopy, and patient and surgical risk factors for complications. METHODS: Patients who underwent hip arthroscopy from 2006 to 2013 were identified in the NSQIP database for the over 400 NSQIP participating hospitals from the United States using Current Procedural Terminology and International Classification of Diseases, Ninth Revision codes. Trends in number of hip arthroscopy procedures per year were analyzed. Complications in the 30-day period after hip arthroscopy were identified. Univariate and multivariate regression analyses were performed to identify risk factors for complications. RESULTS: We identified 1,338 patients who underwent hip arthroscopy, with a mean age of 39.5 ± 13.0 years. Female patients comprised 59.6%. Hip arthroscopy procedures became 25 times more common in 2013 than 2006 (P < .001). Major complications occurred in 8 patients (0.6%), and minor complications occurred in 11 patients (0.8%); overall complications occurred in 18 patients (1.3%) (1 patient had 2 complications). The most common complications were bleeding requiring a transfusion (5, 0.4%), return to the operating room (4, 0.3%), superficial infection not requiring return to the operating room (3, 0.2%), deep venous thrombosis (2, 0.1%), and death (2, 0.1%). Multivariate analysis showed that regional/monitored anesthesia care as opposed to general anesthesia (P = .005; odds ratio, 0.102) and a history of patient steroid use (P = .05; odds ratio, 8.346) were independent predictors of minor complications in the 30 days after hip arthroscopy. CONCLUSIONS: Hip arthroscopy is an increasingly common procedure, with a 25-fold increase from 2006 to 2013. There is a low incidence of 30-day postoperative complications (1.3%), most commonly bleeding requiring a transfusion, return to the operating room, and superficial infection. Regional/monitored anesthesia care and steroid use were independent risk factors for minor complications. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Radiographic Comparison of Anterior Acetabular Rim Morphology Between Pincer Femoroacetabular Impingement and Control.

PURPOSE: To define and compare 3 new parameters (anterior rim angle [ARA], anterior wall angle [AWA], and anterior margin ratio [AMR]), in addition to the lateral center-edge angle of Wiberg and the Tönnis angle, for measuring pincer-type femoroacetabular impingement (FAI) in an asymptomatic versus symptomatic FAI population. METHODS: We reviewed anteroposterior pelvis radiographs of patients verified to have no hip complaints between December 2009 and December 2011. We also reviewed anteroposterior pelvis radiographs of patients who underwent a rim-trimming procedure for pincer FAI between December 2010 and December 2011. Patients aged older than 65 years or younger than 18 years were excluded. Radiographs with a Tönnis grade of 2 or greater were also excluded. For the group of patients with symptomatic hip impingement, radiographs that did not have a crossover sign were excluded. The 2 cohorts were matched for age, sex, and body mass index. Measurements included the Tönnis angle, lateral center-edge angle of Wiberg, ARA, AWA, and AMR. These measurements were compared between the groups. RESULTS: Seventy-two asymptomatic hips were measured. There were 44 female patients (61%) and 28 male patients (39%), aged 25 to 51 years, in the asymptomatic group. The mean ARA was 88.91° ± 8.06°, the mean AWA was 34.89° ± 8.09°, and the mean AMR was 0.49 ± 0.15. Seventy-two symptomatic hips were measured. There were 40 female patients (56%) and 32 male patients (44%), aged 27 to 58 years, in the symptomatic group. The mean ARA was 82.98° ± 10.82°, the mean AWA was 39.11° ± 9.00°, and the mean AMR was 0.56 ± 0.14. The mean difference in the ARA between asymptomatic patients and symptomatic patients was 5.92° (P = .0001). The mean difference in the AWA was 4.22° (P = .0019). The mean difference in the AMR was 0.07 (P = .0039). CONCLUSIONS: Our study provides information on several measurements within an asymptomatic cohort and a symptomatic cohort. Although we found statistically significant differences between the 2 populations, the clinical significance remains unknown. We recommend using this asymptomatic population as a guideline for limits on resection of the anterior acetabular rim. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Treatment of Ulnar Collateral Ligament Injuries and Superior Labral Tears by Major League Baseball Team Physicians.

PURPOSE: To determine practice patterns of Major League Baseball (MLB) team orthopaedic surgeons in addressing the controversial topics of ulnar collateral ligament (UCL) tears, type II SLAP tears, and partial-thickness rotator cuff tear. METHODS: Seventy-four MLB team orthopaedic surgeons were surveyed via an online survey system. A 14-question survey was used to assess surgeon experience, technique, and graft choice for UCL reconstruction (UCLR), treatment of type II SLAP tears, and other common pathologic conditions. RESULTS: Thirty team orthopaedic surgeons (41%) responded (mean experience as team physicians: 9.37 ± 6.33 years). Seventeen (56.7%) surgeons use the docking technique for UCLR whereas 20% use the modified Jobe technique. Nineteen (63.3%) use palmaris longus autograft in UCLR. Overall, 28 (93.3%) do not routinely perform elbow arthroscopy or perform an obligatory transposition of the ulnar nerve in patients without preoperative ulnar nerve symptoms. Twenty-eight (93.3%) would repair a type II SLAP tear, whereas only 1 (3.3%) would debride the tear. No surgeon would perform a concomitant biceps tenodesis, either open or arthroscopic. CONCLUSIONS: Most MLB team orthopaedic surgeons perform a UCLR using the docking technique with a palmaris longus autograft without concomitant elbow arthroscopy or obligatory transposition of the ulnar nerve. The overwhelming majority of these surgeons would also treat an operative type II SLAP tear with a SLAP repair. CLINICAL RELEVANCE: The number of UCLRs and SLAP repairs performed on MLB pitchers has significantly increased over the past 10 years. To properly treat these conditions in elite, college, and recreational athletes, it is important to understand how the surgeons who take care of the most elite-level athletes treat them, and how they are able to reproducibly attain excellent outcomes. This study shows how these common shoulder and elbow injuries are treated by those surgeons who care for the most elite overhead-throwing athletes in the world.

Closure of patellar tendon defect in anterior cruciate ligament reconstruction with bone-patellar tendon-bone autograft: systematic review of randomized controlled trials.

PURPOSE: This study aimed to systematically review the highest level of evidence on anterior cruciate ligament (ACL) reconstruction with bone-patellar tendon-bone (BPTB) autografts with patellar tendon defect closure versus no closure after surgery. METHODS: We performed a systematic review of multiple medical databases using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Level I and Level II randomized controlled trials comparing patellar tendon defect closure to no closure during ACL reconstruction with BPTB autografts were included. Two independent reviewers analyzed all studies. Descriptive statistics were calculated. Study methodological quality was analyzed using the Modified Coleman Methodology Score (MCMS) and Jadad scale. RESULTS: Four studies with a combined 221 patients (154 male patients and 67 female patients) with an average age of 26.6 ± 2.4 years (range, 17 to 54 years) were included. All studies randomized patients before surgery into ACLR with BPTB autografts either with patellar tendon defect closure or without closure. There were no differences in clinical outcomes (Lysholm score, Tegner scale, International Knee Documentation Committee [IKDC] classification, modified Larsen score, and Lauridsen rating) between groups. There were no significant differences in knee pain between groups. All studies reported imaging findings of the patellar tendon defect, with 2 studies showing no difference in appearance between groups, one study showing excessive scar formation with defect repair, and one study showing improved restoration of normal tendon appearance with defect repair. The overall quality of the studies was poor, with all studies scoring less than 46 (average, 40.5 ± 4.7) on the MCMS and scoring 1 on the Jadad scale. CONCLUSIONS: Based on this systematic review of 4 randomized trials, there are no statistically significant or clinically relevant differences in outcomes between patients who have the patellar tendon defect closed and those who have it left open after ACLR with BPTB autografts. The methodology of the included studies limits the interpretation of the data, as evidenced by low MCMS and Jadad scores. LEVEL OF EVIDENCE: Level II, systematic review of Level I and Level II studies.

Is there a higher failure rate of allografts compared with autografts in anterior cruciate ligament reconstruction: a systematic review of overlapping meta-analyses.

PURPOSE: Multiple meta-analyses of randomized controlled trials (RCTs), the highest available level of evidence, have been conducted to determine whether autograft or allograft tissue provides superior clinical outcomes and structural healing in anterior cruciate ligament reconstruction (ACLR); however, results are discordant. The purpose of this study was to conduct a systematic review of meta-analyses comparing ACLR with autografts and allografts to elucidate the cause of discordance and to determine which meta-analyses provide the current best available evidence. METHODS: In this study we evaluated available scientific support for autograft versus allograft use in ACLR by systematically reviewing the literature for published meta-analyses. Data regarding patient outcomes and structural healing were extracted from these meta-analyses. Meta-analysis quality was assessed using the Oxman-Guyatt and Quality of Reporting of Meta-analyses (QUOROM) systems. The Jadad algorithm was then applied to determine which meta-analyses provided the highest level of evidence. RESULTS: Eight meta-analyses containing a total of 15,819 patients met the eligibility criteria, 2 of which included Level II evidence and 6 of which included Level III/IV evidence. Four meta-analyses found no differences between autografts and allografts for patient outcomes, whereas 4 found autografts superior in one or more respects. Four meta-analyses reported higher graft rupture rates in the allograft group, and 2 found superior hop test performance in autograft-treated patients. Six meta-analyses had low Oxman-Guyatt scores (<4) indicative of major flaws. CONCLUSIONS: According to this systematic review of overlapping meta-analyses comparing autografts and allografts for ACLR, the current best available evidence suggests no differences in rupture rates and clinical outcomes. Lower quality meta-analyses indicate that autografts may provide a lower rerupture rate, better hop test performance, and better objective knee stability than do allografts. LEVEL OF EVIDENCE: Systematic review of Level II, III, and IV meta-analyses.

Application of the Goutallier/Fuchs Rotator Cuff Classification to the Evaluation of Hip Abductor Tendon Tears and the Clinical Correlation With Outcome After Repair.

PURPOSE: To assess the reliability and reproducibility of the Goutallier/Fuchs classification for the evaluation of abductor tendon tears of the hip, as well as to identify the relation between preoperative tear size, abductor muscle quality, and the success of endoscopic tendon repair. METHODS: This is a retrospective review of 30 consecutive endoscopic abductor tendon repairs performed by a single surgeon over a 2-year period. Preoperative magnetic resonance imaging scans were reviewed, and the muscle was assigned a grade according to the Goutallier/Fuchs classification. Patient-rated outcome scores--visual analog scale score, Hip Outcome Score (HOS), and modified Harris Hip Score (mHHS)--were collected preoperatively and at a minimum of 2 years postoperatively. Intraobserver and interobserver reliability for muscle grading was calculated. Postoperative outcome measures were compared with preoperative tear size, muscle grade, and repair type to assess for correlations. RESULTS: Of the 30 hips included in the study, over 75% were classified as grade 1 (n = 15) or grade 2 (n = 8). The intraobserver reliability and interobserver reliability of the classification system averaged 0.872 and 0.916, respectively. Two patients (grades 3 and 4) had repair failure and underwent muscle transfer. In the remaining 28 hips, improvement was seen in the visual analog scale score (6.0 v 1.7, P < .0001), HOS-Activities of Daily Living subscale score (58.8 v 83.4, P < .0001), HOS-Sport-Specific subscale score (40.0 v 75.0, P < .0001), and mHHS (55.6 points v 81.1 points, P < .0001) postoperatively. Increasing preoperative fatty infiltration and atrophy correlated with increased postoperative pain levels (regression coefficient, 0.93; P < .001) and decreased postoperative HOS-Activities of Daily Living subscale scores (regression coefficient, -3.36; P = .011), HOS-Sport-Specific subscale scores (regression coefficient, -5.63; P = .016), mHHS values (regression coefficient, -3.50; P = .0008), and patient satisfaction (regression coefficient, -1.04; P < .0001). Patient age, tear size, or repair type (double v single row) did not affect postoperative outcomes. CONCLUSIONS: The Goutallier/Fuchs classification system can be reliably and reproducibly applied to the evaluation of abductor tendon tears of the hip and appears to correlate with patient-rated outcomes after repair. Increasing preoperative muscle fatty atrophy correlates with increased patient pain and decreased patient satisfaction and functional outcomes after repair. LEVEL OF EVIDENCE: Level IV, prognostic case series.

Bioabsorbable versus metallic interference screws in anterior cruciate ligament reconstruction: a systematic review of overlapping meta-analyses.

PURPOSE: Multiple meta-analyses of randomized controlled trials have been conducted to compare clinical and functional outcomes after anterior cruciate ligament (ACL) reconstruction using metallic interference screw (MIS) versus bioabsorbable interference screw (BIS) fixation, but discrepancies in their findings have prevented a consensus conclusion. The purposes of this study were (1) to conduct a systematic review of meta-analyses comparing MISs and BISs in ACL reconstruction, (2) to provide surgical treatment recommendations for ACL graft fixation based on the highest available evidence, and (3) to propose future research avenues in areas of practice lacking high-level evidence. METHODS: The literature was systematically reviewed to identify meta-analyses comparing MISs and BISs in ACL reconstruction. Data were extracted for clinical and functional outcomes, and methodologic quality was assessed using the validated Quality of Reporting of Meta-analyses and Oxman-Guyatt systems. To determine which meta-analyses provided the current best available evidence, the Jadad decision algorithm was used. RESULTS: One Level I and 2 Level II meta-analyses were included. None showed differences between BISs and MISs in validated outcome scores, pivot-shift testing, KT arthrometry (MEDmetric, San Diego, CA), or loss of knee motion. Subgroup analyses found no differences in clinical outcomes or knee stability across biomaterials. All meta-analyses were of high quality according to the Quality of Reporting of Meta-analyses and Oxman-Guyatt systems. Two meta-analyses were determined by the Jadad algorithm to represent the current best available evidence. Both studies showed prolonged knee effusion with BIS use, with 1 also showing an increased incidence of femoral tunnel widening and screw breakage with BIS use. CONCLUSIONS: Whereas clinical and functional outcomes are similar with MISs and BISs, prolonged knee effusion, femoral tunnel widening, and screw breakage are more common with BIS use. Future cost-effectiveness analyses may help weigh the known advantages of BISs against their costs and adverse-event profile. LEVEL OF EVIDENCE: Level II, systematic review of Level I and II studies.

Does Double-Bundle Anterior Cruciate Ligament Reconstruction Improve Postoperative Knee Stability Compared With Single-Bundle Techniques? A Systematic Review of Overlapping Meta-analyses.

PURPOSE: Multiple meta-analyses of randomized controlled trials, the highest available level of evidence, have been conducted to determine whether double-bundle (DB) or single-bundle (SB) anterior cruciate ligament reconstruction (ACL-R) provides superior clinical outcomes and knee stability; however, results are discordant. The purpose of this study was to conduct a systematic review of meta-analyses comparing SB and DB ACL-R to discern the cause of the discordance and to determine which of these meta-analyses provides the current best available evidence. METHODS: We evaluated available scientific support for SB as compared with DB ACL-R by systematically reviewing the literature for published meta-analyses. Data on patient clinical outcomes and knee stability (as measured by KT arthrometry and pivot-shift testing) were extracted. Meta-analysis quality was judged using the Oxman-Guyatt and Quality of Reporting of Meta-analyses systems. The Jadad algorithm was then applied to determine which meta-analyses provided the highest level of evidence. RESULTS: Nine meta-analyses were included, of which 3 included Level I Evidence and 6 included both Level I and Level II Evidence. Most studies found significant differences favoring DB reconstruction on pivot-shift testing, KT arthrometry measurement of anterior tibial translation, and International Knee Documentation Committee objective grading. Most studies detected no significant differences between the 2 techniques in subjective outcome scores (Tegner, Lysholm, and International Knee Documentation Committee subjective), graft failure, or complications. Oxman-Guyatt and Quality of Reporting of Meta-analyses scores varied, with 2 studies exhibiting major flaws (Oxman-Guyatt score <3). After application of the Jadad decision algorithm, 3 concordant high-quality meta-analyses were selected, with each concluding that DB ACL-R provided significantly better knee stability (by KT arthrometry and pivot-shift testing) than SB ACL-R but no advantages in clinical outcomes or risk of graft failure. CONCLUSIONS: The current best available evidence suggests that DB ACL-R provides better postoperative knee stability than SB ACL-R, whereas clinical outcomes and risk of graft failure are similar between techniques. LEVEL OF EVIDENCE: Level II, systematic review of Level I and II studies.

Revision Hip Arthroscopy: A Systematic Review of Diagnoses, Operative Findings, and Outcomes.

PURPOSE: To determine indications for, operative findings of, and outcomes of revision hip arthroscopy. METHODS: A systematic review was registered with PROSPERO and performed based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Therapeutic clinical outcome studies reporting the indications for, operative findings of, and outcomes of revision hip arthroscopy were eligible for inclusion. All study-, patient-, and hip-specific data were extracted and analyzed. The Modified Coleman Methodology Score was used to assess study quality. RESULTS: Five studies were included (348 revision hip arthroscopies; 333 patients; mean age, 31.4 ± 4.2 years; 60% female patients). All 5 studies were either Level III or IV evidence. The surgeon performing revision hip arthroscopy was the same as the primary hip surgeon in only 25% of cases. The mean time between primary and revision hip arthroscopy was 27.8 ± 7.0 months (range, 2 to 193 months). Residual femoroacetabular impingement was the most common indication for and operative finding of revision hip arthroscopy (81% of cases). The most commonly reported revision procedures were femoral osteochondroplasty (24%) and acetabuloplasty (18%). The modified Harris Hip Score was used in all 5 analyzed studies, with significant (P < .05) improvements observed in all 5 studies (weighted mean, 56.8 ± 3.6 preoperatively v 72.0 ± 8.3 at final follow-up [22.4 ± 9.8 months]; P = .01). Other patient-reported outcomes (Non-Arthritic Hip Score, Hip Outcome Score, 33-item International Hip Outcome Tool, Short Form 12) showed significant improvements but were not used in all 5 analyzed studies. After revision hip arthroscopy, subsequent reported operations were hip arthroplasty in 11 patients and re-revision hip arthroscopy in 8 patients (5% total reoperation rate). CONCLUSIONS: Revision hip arthroscopy is most commonly performed for residual femoroacetabular impingement, with statistically significant and clinically relevant improvements shown in multiple patient-reported clinical outcome scores at short-term follow-up. The reoperation rate after revision hip arthroscopy is 5% within 2 years, including further arthroscopy or conversion to hip arthroplasty. LEVEL OF EVIDENCE: Level IV, systematic review of Level III and IV studies.